Provider Demographics
NPI:1306832688
Name:WAKEFIELD, KENNETH JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOHN
Last Name:WAKEFIELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4304 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9414
Mailing Address - Country:US
Mailing Address - Phone:208-664-3576
Mailing Address - Fax:
Practice Address - Street 1:3731 N RAMSEY RD
Practice Address - Street 2:SUITE 150
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9000
Practice Address - Country:US
Practice Address - Phone:208-665-1552
Practice Address - Fax:208-665-1558
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9596207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
F71211Medicare UPIN